- Email: [email protected]
Dolichoectasia involving the vertebrobasilar and carotid artery systems
1344
Case Reports / Journal of Clinical Neuroscience 16 (2009) 1344–1346
bined transhorizontal-supracerebellar approach to MVD for TN.13 In addition to a supracerebellar approach, arachnoid dissection of the cerebellar horizontal fissure and the vein of the great horizontal fissure allowed easy observation of the whole surface of the trigeminal nerve. Nonetheless, sectioning of the SPV is sometimes necessary to obtain adequate exposure of the trigeminal nerve. In such situations, sectioning of the vein should be restricted to small-calibre tributaries, and the vein of the cerebellopontine fissure, which is the largest vein among the tributaries of the SPV and drains most of the petrosal surface of the cerebellum and much of the lower brainstem,3,4 must be preserved. Sacrifice of the vein of the cerebellopontine fissure may lead to extensive venous infarction of the posterior fossa. TN is not a life-threatening disorder, and steps should be taken to minimize the morbidity and mortality resulting from MVD. The SPV should be closely monitored to reduce the risk of venous complications, even though they occur rarely. References 1. McLaughlin MR, Jannetta PJ, Clyde BL, et al. Microvascular decompression of cranial nerves: lessons learned after 4400 operations. J Neurosurg 1999;90:1–8. 2. Choudhari KA. Superior petrosal vein in trigeminal neuralgia. Br J Neurosurg 2007;21:288–92.
3. Matsushima T, Rhoton Jr AL, de Oliveira E, et al. Microsurgical anatomy of the veins of the posterior fossa. J Neurosurg 1983;59:63–105. 4. Rhoton Jr AL. The posterior fossa veins. Neurosurgery 2000;47(Suppl.):S69–92. 5. Samii M, Tatagiba M, Carvalho GA. Retrosigmoid intradural suprameatal approach to Meckel’s cave and the middle fossa: surgical technique and outcome. J Neurosurg 2000;92:235–41. 6. McLaughlin MR, Jannetta PJ, Subach BR, et al. Coagulation of the petrosal vein for MVD (Letter). J Neurosurg 1999;90:1148. 7. Chen HJ, Lui CC. Peduncular hallucinosis following microvascular decompression for trigeminal neuralgia: report of a case. J Formos Med Assoc 1995;94:503–5. 8. Daljit S, Anita J, Sanjiv S. Brain stem infarction: a complication of microvascular decompression for trigeminal neuralgia. Neurol India 2006;54:325–6. 9. Koerbel A, Wolf SA, Kiss A. Peduncular hallucinosis after sacrifice of veins of the petrosal venous complex for trigeminal neuralgia. Acta Neurochir (Wien) 2007;149:831–2. 10. Ryu H, Yamamoto S, Sugiyama K, et al. Neurovascular decompression for trigeminal neuralgia in elderly patients. Neurol Med Chir (Tokyo) 1999;39:226–30. 11. Strauss C, Naraghi R, Bischoff B, et al. Contralateral hearing loss as an effect of venous congestion at the ipsilateral inferior colliculus after microvascular decompression: report of a case. J Neurol Neurosurg Psychiatry 2000;69:679–82. 12. Tsukamoto H, Matsushima T, Fujiwara S, et al. Peduncular hallucinosis following microvascular decompression for trigeminal neuralgia: case report. Surg Neurol 1993;40:31–4. 13. Fujimaki T, Kirino T. Combined transhorizontal-supracerebellar approach for microvascular decompression of trigeminal neuralgia. Br J Neurosurg 2000;14:531–4.
doi:10.1016/j.jocn.2008.12.020
Dolichoectasia involving the vertebrobasilar and carotid artery systems Satoru Takeuchi *, Yoshio Takasato, Hiroyuki Masaoka, Takanori Hayakawa, Naoki Otani, Yoshikazu Yoshino, Hiroshi Yatsushige, Takashi Sugawara Department of Neurosurgery, National Hospital Organization Disaster Medical Center, 3256 Midori-cho, Tachikawa-shi, Tokyo 190-0014, Japan
a r t i c l e
i n f o
Article history: Received 8 September 2008 Accepted 14 December 2008
Keywords: Carotid artery Cerebral infarction Dolichoectasia Vertebrobasilar artery
a b s t r a c t Dolichoectasia is an angiopathy characterized by dilatation, elongation, and tortuosity of the brain arteries. It most frequently involves the vertebral and basilar arteries; involvement of both the vertebrobasilar and carotid systems is rare. We present a patient with fatal dolichoectasia involving both the vertebrobasilar and carotid artery systems. Ó 2009 Elsevier Ltd. All rights reserved.
1. Introduction
2. Case report
Dolichoectasia is an angiopathy characterized by dilatation, elongation, and tortuosity of the brain arteries.1 The prevalence of dolichoectasia is estimated to be 0.05% to 0.06%.1–3 Dolichoectasia most frequently involves the vertebral and basilar arteries.1 Involvement of both the vertebrobasilar and carotid systems is rare. We present a patient with fatal dolichoectasia involving both the vertebrobasilar and carotid artery systems.
A 67-year-old male presented with a reduced level of consciousness. On admission, physical examination revealed a conscious level of 5 on the Glasgow Coma Scale, a blood pressure of 189/124 mmHg and pulse rate of 117 beats per minute. Neurologic examination revealed tetraplegia. A brain CT scan showed remarkable dilatation of the vertebrobasilar and bilateral carotid artery systems (Fig. 1). A brain MRI revealed left-sided vertebral artery (VA) dolichoectasia compressing the left side of the medulla with deviation to the right. Cerebral infarcts of the right occipital lobe and the brainstem were also demonstrated (Fig. 2). Magnetic resonance angiography (MRA) of the brain and threedimensional CT angiography (3D-CTA) demonstrated dilatation that involved bilateral VAs, the basilar artery (BA), bilateral internal
* Corresponding author. Tel.: +81 42 526 5511; fax: +81 42 526 5548. E-mail address: [email protected] (S. Takeuchi).
Case Reports / Journal of Clinical Neuroscience 16 (2009) 1344–1346
1345
Fig. 1. Axial brain CT scan showing dilatation of the vertebrobasilar and bilateral carotid artery systems. A low-density area in the right occipital lobe is also seen.
Fig. 2. (Left to right) Axial T1-weighted, axial T2-weighted and diffusion-weighted brain MRI showing left-sided vertebral artery dolichoectasia compressing the left side of the medulla with deviation to the right. Cerebral infarcts of the right occipital lobe and the brainstem are also shown.
Fig. 3. Magnetic resonance angiography of the brain (left) and three-dimensional CT angiography (right) showing dilatation involving bilateral vertebral arteries (VA), the basilar artery (BA), bilateral internal carotid arteries (ICA), bilateral middle cerebral arteries (MCA), and the A1 portion of the right anterior cerebral artery. The arrow denotes occlusion of the basilar trunk.
1346
Case Reports / Journal of Clinical Neuroscience 16 (2009) 1346–1348
carotid arteries, bilateral middle cerebral arteries, and the A1 portion of the right anterior cerebral artery (Fig. 3). Occlusion of the basilar trunk was also observed (Fig. 3). The patient was treated conservatively but died 8 days after admission. Autopsy consent was not obtained so a histological examination could not be performed. 3. Discussion Autopsy consent was not obtained for this patient so diagnosis was by imaging. Atherosclerotic degeneration of the vascular wall, either alone or associated with arterial hypertension, has been proposed as the initial pathogenic factor in the development of this condition.4,5 This patient had hypertension, but his disease history could not be determined on the basis of available images. Dolichoectasia most frequently involves the VA and BA,1 involvement of the carotid arteries is rare.3 Dolichoectasia that involves the vertebrobasilar and carotid systems is extremely rare.6,7 To our knowledge, dolichoectasia involving all main trunks of the intracranial artery (as in our patient) has not been reported. There are several clinical manifestations of dolichoectasia: ischemia, intracranial hemorrhage, compression of cranial nerves or the brainstem, and obstructive hydrocephalus.1,8,9 Death was likely a result of cerebral infarction due to obstruction of the BA and compression of the brainstem. Traditionally, the diagnosis of dolichoectasia has been based on catheter angiography. MRI or 3D-CTA also show the vascular structures.10,11 In our patient, MRI, MRA and 3D-CTA were used to diagnose dolichoectasia.
4. Conclusion We have presented a patient with dolichoectasia that involves the vertebrobasilar and carotid artery systems. Death was likely a result of cerebral infarction due to obstruction of the BA, and compression of the brainstem. MRI, MRA and 3D-CTA were used to diagnose dolichoectasia. References 1. Yu YL, Moseley IF, Pullicino P, et al. The clinical picture of ectasia of the intracerebral arteries. J Neurol Neurosurg Psychiatry 1982;45:29–36. 2. Courville CB. Arteriosclerotic aneurysms of the circle of Willis. Some notes on their morphology and pathogenesis. Bull Los Angel Neuro Soc 1962;27:1–13. 3. Caplan LR. Dilatative arteriopathy (dolichoectasia): what is known and not known. Ann Neurol 2005;57:469–71. 4. Nijensohn DE, Saez RJ, Reagan TJ. Clinical significance of basilar artery aneurysms. Neurology 1974;24:301–5. 5. Svien HJ, Peserico L. Occlusion of the third ventricle by tortuous, bulbous, calcified basilar artery. Neurology 1959;9:836–8. 6. Borota L, Jonasson P. Basilar and bilateral carotid dolichoectasia with spontaneous dissection of C2 segment of the internal carotid artery. AJNR Am J Neuroradiol 2006;27:1241–4. 7. Romi F, Kråkenes J, Thomassen L, et al. Dolichoectasia of the intracranial arteries and stroke. Tidsskr Nor Laegeforen 1999;119:3004–5. 8. Moseley IF, Holland IM. Ectasia of the basilar artery: the breadth of the clinical spectrum and the diagnostic value of computed tomography. Neuroradiology 1979;18:83–91. 9. Passero S, Filosomi G. Posterior circulation infarcts in patients with vertebrobasilar dolichoectasia. Stroke 1998;29:653–9. 10. Vieco PT, Maurin III EE, Gross CE. Vertebrobasilar dolichoectasia: evaluation with CT angiography. AJNR Am J Neuroradiol 1997;18:1385–8. 11. Iwama T, Andoh T, Sakai N, et al. Dissecting and fusiform aneurysms of vertebrobasilar systems. MR imaging. Neuroradiology 1990;32:272–9.
doi:10.1016/j.jocn.2008.12.022
Postoperative intracerebral and intraventricular hemorrhages following removal of a chronic subdural hematoma Sévérien Muneza a,*, M. Rampanjato Rasoloherimampiononiaina b, Marie Jeanne Nduwamariya a a b
Department of Surgery, Centre Hospitalier Universitaire de Kigali, P.O. Box 4652, Nyarugenge, Kigali, Rwanda Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire de Kigali, Nyarugenge, Kigali, Rwanda
a r t i c l e
i n f o
Article history: Received 16 September 2008 Accepted 8 December 2008
Keywords: Chronic subdural hematoma Intracerebral hemorrhage Intraventricular hemorrhage Remote site
a b s t r a c t We report a patient with multiple intracerebral and intraventricular hemorrhages after removal of bilateral chronic subdural hematomas (CSDH). Possible mechanisms include a sudden increase in cerebral blood flow within fragile cerebral vessels following decompression of CSDH, defective vascular autoregulation, and damage to the cerebral vascular tree. Clinical awareness of this complication and slow decompression of CSDH are stressed. Ó 2009 Elsevier Ltd. All rights reserved.
1. Introduction Chronic subdural hematoma (CSDH) commonly affects elderly patients, usually following head trauma, and has a mortality rate of 0.5% to 4.0%.1 Although the neurosurgical procedure for CSDH is largely benign, complications including cerebral edema, tension pneumocephalus, recurrence of hematoma, seizure, and failure of the brain to re-expand, may impair the postoperative course.2–4 * Corresponding author. Tel.: +250 08462522; fax: +250 576638. E-mail addresses: [email protected], [email protected] (S. Muneza).
The most insidious complication after removal of CSDH is intracerebral hematoma (ICH).1–4 We report a patient with multiple postoperative ICHs and intraventricular hemorrhage (IVH) occurring at remote sites following burr-hole evacuation of bilateral CSDH. 2. Case report An 85-year-old male was admitted with loss of consciousness following a persistent headache, without significant history of head trauma. A cranial CT scan showed a bilateral CSDH, more marked on the left, with noticeable ventricular compression and a prominent midline shift (Fig. 1). There was no arterial hyperten-
Case Reports / Journal of Clinical Neuroscience 16 (2009) 1344–1346
bined transhorizontal-supracerebellar approach to MVD for TN.13 In addition to a supracerebellar approach, arachnoid dissection of the cerebellar horizontal fissure and the vein of the great horizontal fissure allowed easy observation of the whole surface of the trigeminal nerve. Nonetheless, sectioning of the SPV is sometimes necessary to obtain adequate exposure of the trigeminal nerve. In such situations, sectioning of the vein should be restricted to small-calibre tributaries, and the vein of the cerebellopontine fissure, which is the largest vein among the tributaries of the SPV and drains most of the petrosal surface of the cerebellum and much of the lower brainstem,3,4 must be preserved. Sacrifice of the vein of the cerebellopontine fissure may lead to extensive venous infarction of the posterior fossa. TN is not a life-threatening disorder, and steps should be taken to minimize the morbidity and mortality resulting from MVD. The SPV should be closely monitored to reduce the risk of venous complications, even though they occur rarely. References 1. McLaughlin MR, Jannetta PJ, Clyde BL, et al. Microvascular decompression of cranial nerves: lessons learned after 4400 operations. J Neurosurg 1999;90:1–8. 2. Choudhari KA. Superior petrosal vein in trigeminal neuralgia. Br J Neurosurg 2007;21:288–92.
3. Matsushima T, Rhoton Jr AL, de Oliveira E, et al. Microsurgical anatomy of the veins of the posterior fossa. J Neurosurg 1983;59:63–105. 4. Rhoton Jr AL. The posterior fossa veins. Neurosurgery 2000;47(Suppl.):S69–92. 5. Samii M, Tatagiba M, Carvalho GA. Retrosigmoid intradural suprameatal approach to Meckel’s cave and the middle fossa: surgical technique and outcome. J Neurosurg 2000;92:235–41. 6. McLaughlin MR, Jannetta PJ, Subach BR, et al. Coagulation of the petrosal vein for MVD (Letter). J Neurosurg 1999;90:1148. 7. Chen HJ, Lui CC. Peduncular hallucinosis following microvascular decompression for trigeminal neuralgia: report of a case. J Formos Med Assoc 1995;94:503–5. 8. Daljit S, Anita J, Sanjiv S. Brain stem infarction: a complication of microvascular decompression for trigeminal neuralgia. Neurol India 2006;54:325–6. 9. Koerbel A, Wolf SA, Kiss A. Peduncular hallucinosis after sacrifice of veins of the petrosal venous complex for trigeminal neuralgia. Acta Neurochir (Wien) 2007;149:831–2. 10. Ryu H, Yamamoto S, Sugiyama K, et al. Neurovascular decompression for trigeminal neuralgia in elderly patients. Neurol Med Chir (Tokyo) 1999;39:226–30. 11. Strauss C, Naraghi R, Bischoff B, et al. Contralateral hearing loss as an effect of venous congestion at the ipsilateral inferior colliculus after microvascular decompression: report of a case. J Neurol Neurosurg Psychiatry 2000;69:679–82. 12. Tsukamoto H, Matsushima T, Fujiwara S, et al. Peduncular hallucinosis following microvascular decompression for trigeminal neuralgia: case report. Surg Neurol 1993;40:31–4. 13. Fujimaki T, Kirino T. Combined transhorizontal-supracerebellar approach for microvascular decompression of trigeminal neuralgia. Br J Neurosurg 2000;14:531–4.
doi:10.1016/j.jocn.2008.12.020
Dolichoectasia involving the vertebrobasilar and carotid artery systems Satoru Takeuchi *, Yoshio Takasato, Hiroyuki Masaoka, Takanori Hayakawa, Naoki Otani, Yoshikazu Yoshino, Hiroshi Yatsushige, Takashi Sugawara Department of Neurosurgery, National Hospital Organization Disaster Medical Center, 3256 Midori-cho, Tachikawa-shi, Tokyo 190-0014, Japan
a r t i c l e
i n f o
Article history: Received 8 September 2008 Accepted 14 December 2008
Keywords: Carotid artery Cerebral infarction Dolichoectasia Vertebrobasilar artery
a b s t r a c t Dolichoectasia is an angiopathy characterized by dilatation, elongation, and tortuosity of the brain arteries. It most frequently involves the vertebral and basilar arteries; involvement of both the vertebrobasilar and carotid systems is rare. We present a patient with fatal dolichoectasia involving both the vertebrobasilar and carotid artery systems. Ó 2009 Elsevier Ltd. All rights reserved.
1. Introduction
2. Case report
Dolichoectasia is an angiopathy characterized by dilatation, elongation, and tortuosity of the brain arteries.1 The prevalence of dolichoectasia is estimated to be 0.05% to 0.06%.1–3 Dolichoectasia most frequently involves the vertebral and basilar arteries.1 Involvement of both the vertebrobasilar and carotid systems is rare. We present a patient with fatal dolichoectasia involving both the vertebrobasilar and carotid artery systems.
A 67-year-old male presented with a reduced level of consciousness. On admission, physical examination revealed a conscious level of 5 on the Glasgow Coma Scale, a blood pressure of 189/124 mmHg and pulse rate of 117 beats per minute. Neurologic examination revealed tetraplegia. A brain CT scan showed remarkable dilatation of the vertebrobasilar and bilateral carotid artery systems (Fig. 1). A brain MRI revealed left-sided vertebral artery (VA) dolichoectasia compressing the left side of the medulla with deviation to the right. Cerebral infarcts of the right occipital lobe and the brainstem were also demonstrated (Fig. 2). Magnetic resonance angiography (MRA) of the brain and threedimensional CT angiography (3D-CTA) demonstrated dilatation that involved bilateral VAs, the basilar artery (BA), bilateral internal
* Corresponding author. Tel.: +81 42 526 5511; fax: +81 42 526 5548. E-mail address: [email protected] (S. Takeuchi).
Case Reports / Journal of Clinical Neuroscience 16 (2009) 1344–1346
1345
Fig. 1. Axial brain CT scan showing dilatation of the vertebrobasilar and bilateral carotid artery systems. A low-density area in the right occipital lobe is also seen.
Fig. 2. (Left to right) Axial T1-weighted, axial T2-weighted and diffusion-weighted brain MRI showing left-sided vertebral artery dolichoectasia compressing the left side of the medulla with deviation to the right. Cerebral infarcts of the right occipital lobe and the brainstem are also shown.
Fig. 3. Magnetic resonance angiography of the brain (left) and three-dimensional CT angiography (right) showing dilatation involving bilateral vertebral arteries (VA), the basilar artery (BA), bilateral internal carotid arteries (ICA), bilateral middle cerebral arteries (MCA), and the A1 portion of the right anterior cerebral artery. The arrow denotes occlusion of the basilar trunk.
1346
Case Reports / Journal of Clinical Neuroscience 16 (2009) 1346–1348
carotid arteries, bilateral middle cerebral arteries, and the A1 portion of the right anterior cerebral artery (Fig. 3). Occlusion of the basilar trunk was also observed (Fig. 3). The patient was treated conservatively but died 8 days after admission. Autopsy consent was not obtained so a histological examination could not be performed. 3. Discussion Autopsy consent was not obtained for this patient so diagnosis was by imaging. Atherosclerotic degeneration of the vascular wall, either alone or associated with arterial hypertension, has been proposed as the initial pathogenic factor in the development of this condition.4,5 This patient had hypertension, but his disease history could not be determined on the basis of available images. Dolichoectasia most frequently involves the VA and BA,1 involvement of the carotid arteries is rare.3 Dolichoectasia that involves the vertebrobasilar and carotid systems is extremely rare.6,7 To our knowledge, dolichoectasia involving all main trunks of the intracranial artery (as in our patient) has not been reported. There are several clinical manifestations of dolichoectasia: ischemia, intracranial hemorrhage, compression of cranial nerves or the brainstem, and obstructive hydrocephalus.1,8,9 Death was likely a result of cerebral infarction due to obstruction of the BA and compression of the brainstem. Traditionally, the diagnosis of dolichoectasia has been based on catheter angiography. MRI or 3D-CTA also show the vascular structures.10,11 In our patient, MRI, MRA and 3D-CTA were used to diagnose dolichoectasia.
4. Conclusion We have presented a patient with dolichoectasia that involves the vertebrobasilar and carotid artery systems. Death was likely a result of cerebral infarction due to obstruction of the BA, and compression of the brainstem. MRI, MRA and 3D-CTA were used to diagnose dolichoectasia. References 1. Yu YL, Moseley IF, Pullicino P, et al. The clinical picture of ectasia of the intracerebral arteries. J Neurol Neurosurg Psychiatry 1982;45:29–36. 2. Courville CB. Arteriosclerotic aneurysms of the circle of Willis. Some notes on their morphology and pathogenesis. Bull Los Angel Neuro Soc 1962;27:1–13. 3. Caplan LR. Dilatative arteriopathy (dolichoectasia): what is known and not known. Ann Neurol 2005;57:469–71. 4. Nijensohn DE, Saez RJ, Reagan TJ. Clinical significance of basilar artery aneurysms. Neurology 1974;24:301–5. 5. Svien HJ, Peserico L. Occlusion of the third ventricle by tortuous, bulbous, calcified basilar artery. Neurology 1959;9:836–8. 6. Borota L, Jonasson P. Basilar and bilateral carotid dolichoectasia with spontaneous dissection of C2 segment of the internal carotid artery. AJNR Am J Neuroradiol 2006;27:1241–4. 7. Romi F, Kråkenes J, Thomassen L, et al. Dolichoectasia of the intracranial arteries and stroke. Tidsskr Nor Laegeforen 1999;119:3004–5. 8. Moseley IF, Holland IM. Ectasia of the basilar artery: the breadth of the clinical spectrum and the diagnostic value of computed tomography. Neuroradiology 1979;18:83–91. 9. Passero S, Filosomi G. Posterior circulation infarcts in patients with vertebrobasilar dolichoectasia. Stroke 1998;29:653–9. 10. Vieco PT, Maurin III EE, Gross CE. Vertebrobasilar dolichoectasia: evaluation with CT angiography. AJNR Am J Neuroradiol 1997;18:1385–8. 11. Iwama T, Andoh T, Sakai N, et al. Dissecting and fusiform aneurysms of vertebrobasilar systems. MR imaging. Neuroradiology 1990;32:272–9.
doi:10.1016/j.jocn.2008.12.022
Postoperative intracerebral and intraventricular hemorrhages following removal of a chronic subdural hematoma Sévérien Muneza a,*, M. Rampanjato Rasoloherimampiononiaina b, Marie Jeanne Nduwamariya a a b
Department of Surgery, Centre Hospitalier Universitaire de Kigali, P.O. Box 4652, Nyarugenge, Kigali, Rwanda Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire de Kigali, Nyarugenge, Kigali, Rwanda
a r t i c l e
i n f o
Article history: Received 16 September 2008 Accepted 8 December 2008
Keywords: Chronic subdural hematoma Intracerebral hemorrhage Intraventricular hemorrhage Remote site
a b s t r a c t We report a patient with multiple intracerebral and intraventricular hemorrhages after removal of bilateral chronic subdural hematomas (CSDH). Possible mechanisms include a sudden increase in cerebral blood flow within fragile cerebral vessels following decompression of CSDH, defective vascular autoregulation, and damage to the cerebral vascular tree. Clinical awareness of this complication and slow decompression of CSDH are stressed. Ó 2009 Elsevier Ltd. All rights reserved.
1. Introduction Chronic subdural hematoma (CSDH) commonly affects elderly patients, usually following head trauma, and has a mortality rate of 0.5% to 4.0%.1 Although the neurosurgical procedure for CSDH is largely benign, complications including cerebral edema, tension pneumocephalus, recurrence of hematoma, seizure, and failure of the brain to re-expand, may impair the postoperative course.2–4 * Corresponding author. Tel.: +250 08462522; fax: +250 576638. E-mail addresses: [email protected], [email protected] (S. Muneza).
The most insidious complication after removal of CSDH is intracerebral hematoma (ICH).1–4 We report a patient with multiple postoperative ICHs and intraventricular hemorrhage (IVH) occurring at remote sites following burr-hole evacuation of bilateral CSDH. 2. Case report An 85-year-old male was admitted with loss of consciousness following a persistent headache, without significant history of head trauma. A cranial CT scan showed a bilateral CSDH, more marked on the left, with noticeable ventricular compression and a prominent midline shift (Fig. 1). There was no arterial hyperten-